Cardiac Evaluation of Children Presenting with Trauma

doi:10.21203/rs.3.rs-3866204/v1

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Cardiac Evaluation of Children Presenting with Trauma

https://doi.org/10.21203/rs.3.rs-3866204/v1

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Elevated plasma levels of cardiac troponin in polytrauma patients may be associated with the severity of injury and mortality.

In this study, we aimed to determine the predictive value of troponin and the effect of cardiac evaluations on prognosis in pediatric patients admitted to the emergency department due to trauma.

In the study, 97 patients aged 0-18 years who presented with trauma were included. The cause and severity of the trauma, electrocardiography and echocardiography results, and laboratory data (biochemical, hemogram, C-reactive protein, pro-BNP, CK-MB, troponin, etc.) of the patients were evaluated.

Falling from height was the most common cause of injury (43%). In 55 (56%) patients, chest trauma was found. Troponin elevation was present in all patients with chest trauma. Troponin levels were found to be statistically significantly higher in patients with chest trauma compared to those who did not have chest trauma (p=0.011). While the mean Sequential Organ Failure Assessment Score (SOFA) of the patients who were discharged was 4.94±2.58, the mean SOFA score of the patients who died was found to be statistically higher with 10.78±1.39 (≤0.01).

Our findings have revealed the prognostic value of cardiac troponins in terms of direct or indirect injury to the heart, especially in pediatric patients with chest trauma. Therefore, in children presenting with chest trauma, determining the cardiac injury by evaluating the electrocardiography results, which can be easily accessed in every health center, and cardiac troponins may be a guide in terms of patient prognosis.

Trauma

troponin

children

prognosis

In previous studies, cardiac involvement due to trauma was evaluated in adults. In our literature review, we found only one article on this subject in children.

What is New:

Our findings reveal the prognostic value of cardiac troponins in terms of direct or indirect impact on the heart, especially in pediatric patients with chest trauma. We think that our article will make a great contribution to the literature, since there is no other study reaching these results.

Trauma is a major public health issue and one of the most important causes of death, especially because it affects the young age group and causes financial and moral loss (1). It is known that in 1/3 of trauma patients, severe chest trauma is the cause of hospitalization, and 20–25% of deaths occur due to chest trauma^1,2. In children, the rib cage is more flexible than adults, making them more prone to thoracic injuries³. Lung contusion may lead to impaired gas exchange followed by hypoxemia, often without evident external signs of injury⁴. In addition, blunt cardiac injuries in children have been reported to cause significant arrhythmias⁵ and even prolonged cardiac dysfunction⁶. Cardiomyocyte injury is determined by evaluating cardiac troponin levels and electrocardiography (ECG) and echocardiography (ECHO) results⁷. Cardiac troponins are considered to be the most sensitive and specific biomarkers for the diagnosis of cardiomyocyte injury. As in other mechanisms, these biomarkers are released into the circulation in the presence of myocardial or cardiomyocyte injury, providing meaningful results for acute cardiac ischemia^8,9. Elevated plasma levels of cardiac troponin in polytrauma patients are associated with the severity of injury and mortality⁷ ; however, their predictive value for cardiac injury is still being discussed¹⁰. In terms of pediatric PT, little is known about the importance of troponin assessment in the emergency department and its role in predicting outcome-related endpoints¹¹.

The aim of this study is to determine the predictive value of troponin, which is used as a biomarker of cardiac injury in practice in pediatric patients admitted to the emergency department due to trauma, and the effect of cardiac evaluation of patients on prognosis.

Study Population

In this study, 97 patients aged 0–18 years, who were admitted to the emergency department of our hospital between January 2015 and January 2022 due to trauma, were included. Sociodemographic characteristics of the patients (age, gender), the cause and severity of the trauma, sequential organ failure assessment score (SOFA), patient progression, electrocardiography and echocardiography results, laboratory data (biochemical, hemogram, C-reactive protein, pro-BNP, CK-MB, troponin, etc.) were evaluated retrospectively. Patients with a medical history of cardiac disease were excluded from the study.

Statistical Analysis

Statistical analysis of the data was performed using SPSS 24 (SPSS Inc., Chicago, Illinois) software. The conformity of the variables to normal distribution was examined using visual (histogram and probability plots) and analytical methods (Kolmogorov-Smirnov/Shapiro-Wilk tests). Descriptive statistics were expressed as median for non-normally distributed variables and as mean for normally distributed variables. For the relationships between variables, at least one of which was non-normally distributed or ordinal, correlation coefficients and statistical significance were calculated using the Spearman’s Rank Correlation or Pearson's Correlation Coefficient. In the comparison of quantitative variables between the two groups, the Student’s T-test or Mann-Whitney U test was used. The Chi-square test was used to compare categorical variables. Statistical significance level (bidirectional) was chosen as α < 0.05.

A total of 97 trauma patients, 32 (33%) female and 65 (67%) male, were included in the study. The mean age and standard deviation score of the female patients were found as 150 ± 55.1 months, and the mean age and standard deviation score of the male patients were found as 100.5 ± 63.1 (Table 1). When the patients were examined according to the trauma mechanisms, blunt injuries were found in 92% and penetrating injuries were found in 8%. Falling from height was the most common cause of injury (43%). In addition, 39.1% of the patients were admitted to hospital due to road traffic accidents (Table 2). The laboratory data of the patients on admission were shown in Table 3. Elevated troponin levels were detected in 60.8% of the patients. The mean duration of hospital stay of the patients was 27.2 days. While 90.8% of the 97 patients were discharged with full recovery, 9.2% (9) of the patients died. Chest trauma was found in 55 (56%) patients. Although there was no statistical difference between the patients with chest trauma and patients who did not have chest trauma in terms of CK and CK-MB, troponin levels were found to be statistically significantly higher in patients with chest trauma (p = 0.011) (Table 4). Electrocardiography was performed in all patients, and sinus tachycardia was detected in 22 (22.6%) patients. Malignant arrhythmia was not detected in any of the patients. Echocardiography was performed in all patients. In only 3 patients, mild pericardial effusion was detected. The mean ejection fraction of the patients was found to be 76.5 ± 2.5%, the mean left ventricular end-diastolic diameter was found to be 39 ± 8.4, and the cardiac functions were found to be within normal limits (Table 5).

The mean troponin value of the patients was 1026.06 ± 3889ng/L, and the mean CK-MB value was 35.9 ± 61.7 µg/L. The mean troponin value of the discharged patients was 1093.5 ± 4078ng/L, and the mean troponin value of the patients who died was 371.2 ± 263ng/L, and no statistically significant difference was found between the two groups. In addition, there was no statistically significant difference between the discharged patients and the patients who died in terms of CK and CK-MB values.

On computed tomography (CT) of the thorax, it was found that 14 (14.4%) of our patients had lung injury and 2 (2.06%) patients had cardiac injury. While the mean Sequential Organ Failure Assessment Score (SOFA) of the patients who were discharged was 4.94 ± 2.58, the mean SOFA score of the patients who died was found to be statistically higher with 10.78 ± 1.39 (≤ 0.01). In terms of troponin value, no statistical difference was found between patients with a SOFA Score of ≤ 7 and patients with a SOFA score of ≥ 8.

In our study, we present the data of a total of 97 pediatric PT patients admitted to our tertiary emergency department. Epidemiologic studies have revealed that in our country, the most common types of accidents after falls from height are road traffic accidents^3,6. In our study, 43% of the patients were admitted to the hospital due to falls from height, and this data is consistent with the findings obtained in previous publications. The high rate of falling from height cases is due to the fact that the air temperature is very high in the summer months in our country, especially in the city of Diyarbakir where this study was carried out, and people sleep on the roofs of their houses. Parents need to be careful in terms of their children falling from heights.

In the study of Balcı et al., patients with chest trauma were evaluated and the male/female ratio was found to be 6.6 (3649/542)¹². Similarly, in our study, chest trauma was found to be more common in male patients (male/female ratio: 2).

In a study, it was found that 70% of chest traumas were blunt injuries and 30% were penetrating injuries, and it was determined that the most common causes of these traumas were road traffic accidents (75.7%) and falls from height (15.8%)¹³. When the patients who were admitted to our hospital were examined according to the cause of trauma, it was found that 92% had blunt injuries and 8% had penetrating injuries.

Evidence on the clinical benefits of the use of cardiac troponins in determining cardiac involvement after chest trauma is limited. Cardiac troponin values measured in 128 patients with chest trauma were found to be elevated in 31% of the patients¹⁴.

Troponin elevation was found in all of our patients with chest trauma. Even if some of these patients had minimal troponin elevation, our study shows the importance of troponin in determining cardiac injury.

ECG changes in patients with trauma are nonspecific and do not directly indicate myocardial contusion but are alerting in terms of cardiac involvement and possible complications¹⁵. Electrocardiography is widely used in the diagnosis of myocardial contusion. In a meta-analysis conducted by Maenza et al., significant cardiac complications were found to be consistent with abnormal ECG findings¹⁶. Blunt cardiac injuries can cause arrhythmias, and high troponin levels may predict the incidence of arrythmias¹⁷. Such arrhythmias have been described previously⁵. In our study, abnormal ECG findings were found in 22 of the 97 patients. Sinus tachycardia was detected in all of these 22 patients. No other pathology was found on electrocardiography. Malignant arrhythmias that would require treatment were not detected in any of our patients. Therefore, we could not clearly explain the relationship between chest trauma and arrhythmia in our study.

Unlike pulmonary contusion, cardiac contusion in children has been reported to be rare^6,18; therefore, the specificity of troponins in determining direct cardiac injury after trauma is questionable. In a large postmortem study, signs of cardiac injury in autopsy were found only in 41 of the 282 children, and most of the patients had died at the scene or soon after admission to hospital¹⁸. In our study, although high troponin levels were observed in 60.8% of the patients, 9.2% of these patients died. This shows that although troponin levels may indicate cardiac injury, the relationship between troponin levels and mortality is not clear. In the analysis of a study conducted in patients admitted to the pediatric intensive care unit, troponin level proved to be a valuable predictor of mortality at the time of admission¹⁹. In our study, although troponin levels were found to be higher in patients who died compared to patients who were discharged, no statistically significant difference between the two groups was found. However, troponin values were found to be statistically significantly higher in patients with chest trauma compared to patients who did not have chest trauma. These data show that troponin level can be a valuable marker in the detection of lung contusion and cardiac injury in children and prove the importance of measuring the troponin levels in pediatric patients with chest trauma.

The role of ECHO in patients with penetrating heart injury is increasing day by day. Although the role of ECHO in the management of blunt trauma in hemodynamically stable patients is still unclear, it is quite useful for excluding structural problems²⁰. Patients with cardiac injuries (rupture or perforation) are at a high risk of death. In clinical series, autopsies performed in patients who died as a result of blunt cardiac trauma have revealed cardiac rupture at a rate of 36%-52%. It is known that patients with cardiac ruptures or perforations often die at the scene or during transport. It has been stated that cardiac rupture may occur in the pericardial cavity, coronary arteries, intrapericardial part of large arteries or veins, and as a result, death may occur secondary to acute cardiac tamponade²¹. In the ECHO results of the patients who were followed up with suspicion of heart injury, abnormal wall motion, regional hypokinesia, right ventricular dilatation, pericardial effusion, ventricular septal defect, ventricular and pericardial contusion were found²². In a prospective study, 49 out of 68 patients who were followed up with ECHO, ECG, and CK-MB tests, were found to have abnormal ECHO, ECG, or CK-MB results²³. On the other hand, in the study conducted by Weiss et al. in 81 patients, no significant correlation was found between ECG changes and ECHO findings²⁴. In studies, the diagnostic success rate of ECHO was found to be 67% and it was acknowledged as one of the best diagnostic methods; in addition, it was stated that patients with normal ECHO and ECG results did not require monitoring in the intensive care²⁴. In our study, bedside echocardiography was performed in all patients. In only 3 patients, mild pericardial effusion was detected. Other patients had normal echocardiographic findings.

Since CK-MB levels increase in skeletal muscle injuries, it is necessary to make a differential diagnosis of patients with skeletal muscle injuries and myocardial injuries. CK-MB is nonspecific in detecting cardiac injury and its role in predicting cardiac contusion and related complications is not clear. In previous studies, it was stated that CK-MB and CK may increase as a normal inflammatory response to injury, and it was determined that CK-MB value increased in most patients with chest trauma^25,26. In studies conducted on cardiac involvement in trauma patients, CK-MB values were found to be increased and a correlation was found between increased CK-MB values, ECHO and ECG findings and other heart enzyme levels. Therefore, increased CK-MB was reported to be a finding indicating cardiac injury^27,28. However, some authors reported that no positive correlation was found between CK-MB values and other test results. They stated that CK-MB test may be unnecessary, expensive and clinically confusing in the diagnosis of contusion and should not be used but may be useful in the diagnosis of arrhythmia and cardiac contractile dysfunction^29,30. In our study, CK-MB and CK values were not found to be statistically significantly higher in children with chest trauma compared to children who did not have chest trauma; therefore, we believe that it cannot be used as a cardiac marker as stated in some previous studies.

Serum troponin value has a high specificity for myocardial contusion. Troponins are released into the blood as a result of loss of myocyte membrane integrity; they are proteins that regulate myocardial contraction and are not secreted from skeletal muscles. In the literature, it has been stated that troponin has a high sensitivity and specificity for the diagnosis of cardiac injury, that it has a higher sensitivity than other markers and may be more valuable than CK-MB in the diagnosis^27,31. However, in an animal study conducted by Bertinchant et al., it was stated that myocardial contusion could not be diagnosed based on the troponin level alone; and in the study of Mair et al., it was reported that no relationship was found between troponin elevation and ECG changes³². In our study, although ECG findings were very rare in the patients (sinus tachycardia was detected in 22% of the patients), troponin elevation was found in all patients with sinus tachycardia. This shows the importance of measuring troponin levels and performing ECG and ECHO, especially in children with chest trauma, for the diagnosis of cardiac involvement.

Cardiac injuries are life-threatening problems in patients with polytrauma, especially chest trauma. However, the actual incidence of cardiac injuries is unknown, since there are no definitive criteria for the diagnosis of cardiac injuries in trauma patients. Electrocardiography is considered to be a sensitive test in the diagnosis of blunt heart injuries. In this regard, all heart rhythm disorders should be carefully evaluated in order not to miss any injury. Evaluation of troponin levels is important in terms of detecting increased risk of death, especially in patients with abnormal ECG results. Among patients presenting with blunt chest trauma, those with a history of cardiac disease, those who are hemodynamically unstable, those with abnormal ECG results, high troponin and CK-MB levels and high trauma severity scores should be followed up with appropriate cardiac monitoring. In addition, patients presenting with chest pain, rib and sternal fractures and lung injuries as a result of blunt chest trauma should be kept under observation for at least 24 hours in terms of blunt heart injury.

In order to predict cardiac injury in pediatric patients with chest trauma, electrocardiography should be performed, and CK-MB and troponin levels should be measured. To detect and treat life-threatening injuries such as pericardial tamponade early, echocardiography should also be performed.

Since no malignant arrhythmia was detected in the patients included in our study, we were not able to present our opinion on arrhythmias that were reported in patients with blunt chest trauma in previous studies.

Acknowledgements: None.

Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Disclosure: The authors declare no conflict of interest.

Author Contributions: M.Y, M.S, A.A, M.T designed the study, M.T, D.U,A.Ş and M.M.T wrote this manuscript, M.Y and M.M.T gave conceptual advice, A.A, M.S,A.Ş and D.U collected and analyzed the data. All authors read and approved the final manuscript.

Ethics approval Approval for the study was obtained from the Ethics Committee of our hospital (Approval date: 15.02.2022 / Approval number: 76).

Consent to participate Not applicable.

Consent for publication Not applicable.

Competing interests The authors have no relevant fnancial or nonfinancial interests to disclose.

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Tables 1 to 5 are available in the Supplementary Files section.

No competing interests reported.

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Cardiac Evaluation of Children Presenting with Trauma

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Abstract

What Is Known

Introduction

Materials and Methods

Study Population

Statistical Analysis

Results

Discussion

Limitations of the Study

Declarations

References

Tables

Additional Declarations

Supplementary Files

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